[Clinico-statistical analysis of the prognostic factors in patients underwent Bentall procedure].
Between March, 1972, and December, 1988, 93 patients had replacement of the ascending aorta and aortic valve with a composite graft (Bentall procedure and its modification). Annuloaortic ectasia was the most common indication for operation (61 patients), followed by DeBakey type I aortic dissection (20 patients) and DeBakey type II dissection (12 patients). Method of the coronary reimplantation included direct one lane coronary orifice anastomosis in 22 patients; direct two lane coronary orifice anastomosis in 52; interposition graft in 9; combination of direct two lane coronary orifice anastomosis and interposition graft in 2; direct two lane anastomosis and brachiocephalic-coronary bypass grafting with saphenous vein in 7; interposition graft and brachiocephalic-coronary bypass grafting in 1. A multivariate logistic regression analysis was made of associations with early mortality. Postoperative severe ventricular arrhythmias were the only independent risk factor (p = 0.0498) and its incidence has declined after the use of cardioplegia for myocardial protection (p = 0.12). The Cox method proportional hazard model was used to identify the incremental risk factors with the late death, which indicated that the anastomotic leakage (p = 0.2394), the preoperative aortic dissection (p = 0.0079), and the residual dissection (p = 0.0035) were the prognosis-related or -determinant factors. As there was the relatively high incidence of anastomotic leak occurring at the coronary artery orifice-graft anastomosis with one lane suture, we have circumferentially buttressed the coronary suture line with several pledget-supported mattress suture--direct two lane coronary orifice suture--for reinforcement. At 10 years after surgery, the actuarial survival rate for the 22 patients with the direct one lane suture was 55% and for the 59 patients with the direct two lane suture, 76% (p = 0.09). The actuarial freedom from reoperation at 10 years for the patients with one lane suture was 64% and for those with two lane suture was 93% (p = 0.05). Further, the interposition graft technique with Piehler method and brachiocephalic-coronary bypass grafting were effective to prevent the anastomotic leakage for those patients with mild dilatation of Valsalva sinus (maximum transverse diameter less than 50 mm) and slight cephalad displacement of coronary ostia (coronary ostia located less than 15 mm above the aortic annulus). For the patients with the dissection of the remaining thoracic and abdominal aorta, the careful follow-up with enhanced CT scan and subsequent operation seemed to be required to improve the late surgical results. The actuarial survival rate for the entire group at 5 and 10 years was 77% and 66%, respectively.(ABSTRACT TRUNCATED AT 400 WORDS)
Seino
R
R
Department of Cardiovascular Surgery, Heart Institute of Japan, Tokyo Women's Medical College.
D000784:Aortic Dissection / Q000401:mortality / Q000601:surgery*; D001011:Aorta / Q000601:surgery; D001014:Aortic Aneurysm / Q000401:mortality / Q000601:surgery*; D001021:Aortic Valve / Q000601:surgery; D001807:Blood Vessel Prosthesis / Q000401:mortality; D006350:Heart Valve Prosthesis / Q000401:mortality; D006801:Humans; D011379:Prognosis; D013514:Surgical Procedures, Operative / Q000379:methods / Q000401:mortality; D015996:Survival Rate